Covered Entity Details

CAH131311-08 ST. LUKE'S ELMORE MEDICAL CENTER (Active) - information as of 5/23/2025 12:10:51 AM

Main Details

Name

ST. LUKE'S ELMORE MEDICAL CENTER

Subdivision Name

ELMORE ST LUKES FAMILY/INTERNAL MEDICINE CLINIC

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH131311-08

Medicare Provider Number

131311

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

5/31/2022

Participating Start Date

7/1/2022

Participating Approval Date

6/1/2022

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

St. Luke's Health System, LTD
Kate Fowler, Senior VP & CFO
(208) 381-8717

Primary Contact

St. Luke's Health System, LTD
Amanda Davis, Pharmacy Business Analyst
(208) 706-1021

Addresses

Street Address

805 N 6TH STREET E
MOUNTAIN HOME, ID 83647

Billing Address

St. Luke's Health System, LTD
190 E Bannock
Boise, ID 83712

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 7/1/2019, terminated 1/1/2022. Reinstated 7/1/2022.	06/01/2022

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Shipping Address 1

St. Luke's Elmore Medical Center
Attn: Pharmacy
895 N Sixth East
Mountain Home, ID 83647

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH131311-01	Child	CAH	ST. LUKE'S ELMORE MEDICAL CENTER	Outpatient Services - Elmore Regional Clinic Outpatient Services	890 N 6th E	Mountain Home	ID	Active
CAH131311-02	Child	CAH	ELMORE MEDICAL CENTER	General Surgery Clinic - ClinicElmore St. Lukes General Surgery Clinic	840 N 4TH E STREET	Mountain Home	ID	Terminated
CAH131311-03	Child	CAH	ELMORE MEDICAL CENTER	Elmore St. Lukes PVL/ECHO - ECHOCARDIOLOGY	840 N 4TH E STREET	Mountain Home	ID	Terminated
CAH131311-04	Child	CAH	ST. LUKE'S ELMORE MEDICAL CENTER	Trinity Mountain Medical Clinic - St Lukes Trinity Mountain Pediatrics	465 McKenna Drive	Mountain Home	ID	Active
CAH131311-05	Child	CAH	ST. LUKE'S ELMORE MEDICAL CENTER	Trinity Mountain Medical Clinic - St. Lukes Trinity Mountain Obstetrics	465 McKenna Drive	Mountain Home	ID	Active
CAH131311-06	Child	CAH	ST. LUKE'S ELMORE MEDICAL CENTER	Trinity Mountain Medical Clinic - St Lukes Trinity Mountain Internal Med	465 McKenna Drive	Mountain Home	ID	Terminated
CAH131311-07	Child	CAH	ST. LUKE'S ELMORE MEDICAL CENTER	Trinity Mountain Medical Clinic - St. Lukes Mountain Family Med	465 McKenna Drive	Mountain Home	ID	Active
CAH131311-08	Child	CAH	ST. LUKE'S ELMORE MEDICAL CENTER	ELMORE ST LUKES FAMILY/INTERNAL MEDICINE CLINIC	805 N 6TH STREET E	MOUNTAIN HOME	ID	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 2:48:34 PM	8/29/2024 6:18:50 PM	8/29/2024 6:18 PM
Details	Last Recertification Date	Update	Recertification	9/16/2022 12:26:00 AM	8/23/2023 2:48:34 PM	8/23/2023 2:48 PM
Contacts	Authorizing Official	Update	Change Request	DiDio, Peter Vice President, Controller St. Lukes Regional Medical Center 2083811251	Fowler, Kate Senior VP & CFO St. Luke's Health System, LTD 2083818717	11/16/2022 11:13 AM
Contacts	Primary Contact	Update	Profile Change Request	Davis, Amanda Pharmacy Business Specialist St. Lukes Regional Medical Center 2087061021	Davis, Amanda Pharmacy Business Analyst St. Luke's Health System, LTD 2087061021	11/15/2022 9:54 AM
Details	Last Recertification Date	Update	Recertification		9/16/2022 12:26:00 AM	9/16/2022 12:26 AM
Details	State	Update		Approved	Active	7/1/2022 12:01 AM
Addresses	Billing Address	Insert	Reinstatement		St. Luke's Health System, LTD 190 E Bannock Boise, ID 83712	6/1/2022 8:49 AM
Details	Last Recertification Date	Update	Reinstatement	9/12/2021 10:35:04 PM		6/1/2022 8:49 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	9/27/2021 12:00:00 AM		6/1/2022 8:49 AM
Dates	Participating Approval Date	Update	Reinstatement	4/16/2019 11:41:15 AM	6/1/2022 8:49:24 AM	6/1/2022 8:49 AM
Details	State	Update	Reinstatement	Terminated	Approved	6/1/2022 8:49 AM
Dates	Registration Date	Update	Reinstatement	4/4/2019 5:12:47 PM	5/31/2022 10:12:33 AM	6/1/2022 8:49 AM
Dates	Signed By Date	Update	Reinstatement	4/10/2019 11:25:04 AM	5/31/2022 1:57:08 PM	6/1/2022 8:49 AM
Dates	Start Date	Update	Reinstatement	7/1/2019 12:00:00 AM	7/1/2022 12:00:00 AM	6/1/2022 8:49 AM
Terminations	Termination Comments	Update	Reinstatement	Services are changing as of 09/27/2021		6/1/2022 8:49 AM
Terminations	Termination Date	Update	Reinstatement	1/1/2022 12:00:00 AM		6/1/2022 8:49 AM
Terminations	Termination Effective Date	Update	Reinstatement	9/27/2021 12:00:00 AM		6/1/2022 8:49 AM
Terminations	Termination Reason	Update	Reinstatement	Business decision by the Covered Entity		6/1/2022 8:49 AM
Details	Comments Public	Insert	Reinstatement		Participated starting 7/1/2019, terminated 1/1/2022. Reinstated 7/1/2022.	6/1/2022 8:23 AM
Details	State	Update		To Be Terminated	Terminated	1/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/27/2021 12:00:00 AM	10/1/2021 7:01 AM
Details	State	Update	Termination Request	Active	To Be Terminated	10/1/2021 7:01 AM
Terminations	Termination Comments	Update	Termination Request		Services are changing as of 09/27/2021	10/1/2021 7:01 AM
Terminations	Termination Date	Update	Termination Request		1/1/2022 12:00:00 AM	10/1/2021 7:01 AM
Terminations	Termination Effective Date	Update	Termination Request		9/27/2021 12:00:00 AM	10/1/2021 7:01 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	10/1/2021 7:01 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 12:36:52 PM	9/12/2021 10:35:04 PM	9/12/2021 10:35 PM
Details	Last Recertification Date	Update	Recertification	9/7/2019 1:00:49 AM	9/1/2020 12:36:52 PM	9/1/2020 12:36 PM
Details	Entity Subname	Update	Change Request	SL FAMILY MEDICINE-BALDRIDGE - ELMORE ST LUKES FAMILY MED	ELMORE ST LUKES FAMILY/INTERNAL MEDICINE CLINIC	6/1/2020 6:52 AM
Details	Last Recertification Date	Update	Recertification		9/7/2019 1:00:49 AM	9/7/2019 1:00 AM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Details	Entity Name	Update	Change Request	ELMORE MEDICAL CENTER	ST. LUKE'S ELMORE MEDICAL CENTER	5/15/2019 12:19 PM
Contacts	Signed By	Insert	New Registration		DiDio, Peter Vice President, Controller St. Lukes Regional Medical Center 2083811251	4/16/2019 11:41 AM
Details	340B ID	Update	New Registration		CAH131311-08	4/16/2019 11:41 AM
Details	Entity Subname	Update	New Registration	SL FAMILY MEDICINE-BALDRIDGE	SL FAMILY MEDICINE-BALDRIDGE - ELMORE ST LUKES FAMILY MED	4/16/2019 11:41 AM
Dates	Participating Approval Date	Update	New Registration		4/16/2019 11:41:15 AM	4/16/2019 11:41 AM
Details	State	Update	New Registration	Pending	Approved	4/16/2019 11:41 AM
Dates	Signed By Date	Update	New Registration		4/10/2019 11:25:04 AM	4/16/2019 11:41 AM
Dates	Start Date	Update	New Registration		7/1/2019 12:00:00 AM	4/16/2019 11:41 AM
Addresses	Main Address	Insert	New Registration		805 N 6TH STREET E MOUNTAIN HOME, ID 83647	4/4/2019 5:12 PM
Addresses	Billing Address	Insert	New Registration		St. Luke's Health System, LTD 190 E Bannock Boise, ID 83712	4/4/2019 5:12 PM
Addresses	Shipping Address	Insert	New Registration		St. Luke's Elmore Medical Center Attn: Pharmacy 895 N Sixth East Mountain Home, ID 83647	4/4/2019 5:12 PM
Contacts	Primary Contact	Insert	New Registration		Davis, Amanda Pharmacy Business Specialist St. Lukes Regional Medical Center 2087061021	4/4/2019 5:12 PM
Contacts	Authorizing Official	Insert	New Registration		DiDio, Peter Vice President, Controller St. Lukes Regional Medical Center 2083811251	4/4/2019 5:12 PM
Details	Last Recertification Date	Insert	New Registration			4/4/2019 5:12 PM
Details	Grant Number	Insert	New Registration			4/4/2019 5:12 PM
Details	340B ID	Insert	New Registration			4/4/2019 5:12 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/4/2019 5:12 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/4/2019 5:12 PM
Details	Medicare Provider Number	Insert	New Registration		131311	4/4/2019 5:12 PM
Details	Entity Name	Insert	New Registration		ELMORE MEDICAL CENTER	4/4/2019 5:12 PM
Details	Program Code	Insert	New Registration		CAH	4/4/2019 5:12 PM
Details	Entity Subname	Insert	New Registration		SL FAMILY MEDICINE-BALDRIDGE	4/4/2019 5:12 PM
Dates	Participating Approval Date	Insert	New Registration			4/4/2019 5:12 PM
Details	State	Insert	New Registration		Pending	4/4/2019 5:12 PM
Dates	Registration Date	Insert	New Registration		4/4/2019 5:12:47 PM	4/4/2019 5:12 PM
Dates	Signed By Date	Insert	New Registration			4/4/2019 5:12 PM
Dates	Start Date	Insert	New Registration			4/4/2019 5:12 PM
Terminations	Termination Comments	Insert	New Registration			4/4/2019 5:12 PM
Terminations	Termination Date	Insert	New Registration			4/4/2019 5:12 PM
Terminations	Termination Effective Date	Insert	New Registration			4/4/2019 5:12 PM
Terminations	Termination Reason	Insert	New Registration			4/4/2019 5:12 PM